Impact of Quality Improvement Bundle on Compliance with Resuscitation Guidelines during In-Hospital Cardiac Arrest in Children

Introduction Various quality improvement (QI) interventions have been individually assessed for the quality of cardiopulmonary resuscitation (CPR). We aimed to assess the QI bundle (hands-on training and debriefing) for the quality of CPR in our children's hospital. We hypothesized that the QI bundle improves the quality of CPR in hospitalized children. Methods We initiated a QI bundle (hands-on training and debriefing) in August 2017. We conducted a before-after analysis comparing the CPR quality during July 2013–May 2017 (before) and January 2018–December 2020 (after). We collected data from the critical events logbook on CPR duration, chest compressions (CC) rate, ventilation rate (VR), the timing of first dose of epinephrine, blood pressure (BP), end-tidal CO2 (EtCO2), and vital signs monitoring during CPR. We performed univariate analysis and presented data as the median interquartile range (IQR) and in percentage as appropriate. Results We compared data from 58 CPR events versus 41 CPR events before and after QI bundle implementation, respectively. The median (IQR) CPR duration for the pre- and post-QI bundle was 5 (1–13) minutes and 3 minutes (1.25–10), and the timing of the first dose of epinephrine was 2 (1-2) minutes and 2 minutes (1–5), respectively. We observed an improvement in compliance with the CC rate (100–120 per minute) from 72% events before versus 100% events after QI bundle implementation (p=0.0009). Similarly, there was a decrease in CC interruptions and hyperventilation rates from 100% to 50% (p=0.016) and 100% vs. 63% (p=<0.0001) events before vs. after QI bundle implementation, respectively. We also observed improvement in BP monitoring from 36% before versus 60% after QI bundle (p=0.014). Conclusion Our QI bundle (hands-on training and debriefing) was associated with improved compliance with high-quality CPR in children.


Introduction
Cardiopulmonary arrest in children is an unfortunate and devastating occurrence [1]. It is estimated that around 6,000 children sufer in-hospital cardiac arrests (IHCA) each year [1,2]. Despite advances in cardiopulmonary resuscitation (CPR), only 22-40% of pediatric patients with IHCA survive hospital discharge [2,3]. Tis variation in survival rates across US hospitals could be contributed to the quality of resuscitation provided, suggesting the importance of delivery of high-quality CPR [4]. According to the 2015 American Heart Association (AHA) guidelines on CPR, the determinants of high-quality CPR include optimal chest compression (CC) rate and depth, minimal interruptions during CC, and timely defbrillation [5]. Despite following these guidelines, research suggests that CPR quality remains suboptimal with poor outcomes in many hospitals [6,7]. Over the past few decades, various quality improvement (QI) interventions have been implemented and individually assessed for optimizing CPR performances and reducing mortality rates [8,9]. However, the data are still limited. Debriefng after CPR events has been associated with improved quality of CPR and survival after IHCA [9]. It ofers an opportunity to identify and address the critical event comprehensively improving the overall resuscitation team performance [9]. We aimed to assess the efectiveness of a qualitative improvement (QI) bundle (hands-on training and debriefng) on compliance with AHA resuscitation guidelines during IHCA in our children's hospital. We hypothesized that the QI bundle improves the quality of CPR in hospitalized children.

Methods
We conducted the retrospective analysis study at the Children's Hospital of San Antonio (CHofSA), a freestanding, 200-bed, tertiary care children's hospital. CHofSA has ICU capacity of 24 beds with 23000 annual ED visits and 5000 annual admissions. Te Baylor College of Medicine institutional review board and CHofSA feasibility committee approved the study. Due to the retrospective observational nature of the study, our IRB approved the study with a waiver of informed consent.
We initiated a QI bundle (hands-on training and debriefng) in August 2017. We conducted a before-after analysis comparing the CPR quality during July 2013-May 2017 (before) and January 2018-December 2020 (after).

Inclusion Criteria.
Inclusion criteria are as follows: children ages 0-21 years who had in-hospital cardiopulmonary arrest (CPA) and undergone cardiopulmonary resuscitation (CPR)

Exclusion
Criteria. Exclusion criteria are as follows: children above 21 years of age/non-CPA event/ Do Not Resuscitate (DNR) CPR events. Our pediatric ICU (PICU) resuscitation committee maintains the log of all the critical events that happened in our hospital. In both pre-and post-QI bundle groups, we used these case logs to collect data from the critical event evaluation sheet to identify patients who underwent CPR for cardiopulmonary arrest (CPA) for our study. We gathered demographic data including age, gender, primary diagnosis, date of admission (DOA), time of the event (TOE), CPR duration, chest compressions (CC) rate, ventilation rate (VR), the timing of frst epinephrine, subsequent doses of epinephrine, blood pressure (BP), endtidal CO 2 (EtCO 2 ) monitoring during CPR. We compared the data for compliance in accordance with AHA guidelines (Table 1) [10].
Our QI bundle involved hands-on CPR training and cold debriefng.

Hands-On Training.
We conducted an annual simulation-based, rapid cycle deliberate practice (RCDP) high-quality CPR training for all the ICU staf including residents, nursing staf, and physicians ( Figure 1). Additionally, we incorporated CPR training for our nursing staf during their annual summer school, which was organized by the nursing department and focused on maintaining competency in diferent hands-on skills for our nurses. RCDP high-quality CPR training included simulation training with multiple, short debriefs and involved coaching related to high-quality CPR with a goal of allowing the participants to reach some level of mastery with high-quality CPR.

Debriefng.
We conducted cold debriefng within 2 weeks of a cardiac arrest event. During the debriefng sessions, we encouraged the participation of the majority of ICU nurses, respiratory therapists, residents, PICU attending, and fellow physicians involved in the case. Any PICU staf member interested in learning from the resuscitation event was encouraged to attend. We used a debriefng checklist that was adopted from a debriefng tool developed and validated previously [11]. We structured our cold debriefng sessions around discussing the pertinent patient histories, events leading to cardiac arrest, resuscitation data, and patient outcomes. Quantitative data such as blood pressure and EtCO 2 readings, defbrillator, and central monitor recordings were presented and discussed (Figures 2 and 3). We also focused on efective teamwork and communication during the event. Te minutes of these debriefngs were disseminated to all the code team members in the unit to help them with the learning process. Te debrief was well received, and a debriefng checklist was developed and implemented over time.

Statistical Analysis.
We entered all the data in a Microsoft Excel spreadsheet and performed univariate analysis and presented data as the median interquartile range (IQR) and in percentage as appropriate. We compared the before and after CPR data using the chi-square test (p ≤ 0.05 considered signifcant).

Results
During the pre (June 2013-March 2017) and post (January 2018-December 2020) QI bundle period, total critical events in our children's hospital were 322 and 194, respectively. After excluding non-CPA events and Do Not Resuscitate (DNR) CPR cases, we collected data on 58 and 41 CPR cases in pre-and post-QI bundle periods, respectively.
Tere were no signifcant changes in EtCO 2 monitoring, events needing subsequent epinephrine, use of calcium, and bicarbonate, and return of spontaneous circulation (ROSC) after QI bundle implementation.

Discussion
In our before and after analysis, we demonstrated that implementation of QI bundle with hands-on training and cold debriefng improved the compliance with high-quality CPR guidelines in children with IHCA. Te CPR parameters, such as chest compression rate, ventilation rates, blood pressure monitoring, were improved signifcantly after QI bundle implementation.
CPR is a lifesaving procedure for patients with cardiac arrest. Te American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care puts emphasis on high-quality CPR-that is, adequate chest compressions rate and depth, minimal interruptions, complete chest recoil, and avoidance of hyperventilation [12,13]. Strategies such as simulation training and debriefng have been increasingly utilized to provide high-quality CPR and to improve resuscitation eforts during management of cardiac arrest [14,15]. Simulation-based CPR training methods allow learners to practice in a realistic scenario, measure CPR parameters and, thus, have been shown to improve resuscitation performance [16,17]. Similarly, the use of debriefng has been considered as an efective tool in improving resuscitation quality [8,18]. An open discussion model during debriefng has shown to be a simple and efective tool in addressing key aspects of the actions taken during cardiac arrest events and gives an opportunity for providers to efciently adapt and improve the team's performance [18]. One study in adult patients compared the efects of debriefng intervention between baseline and intervention periods and found that  Critical Care Research and Practice debriefng methods improved the rates of ROSC [19]. However, the data demonstrating clinical improvements using simulation training or debriefng alone are still limited.
Many institutes have adopted CPR bundles to improve the outcomes of IHCA [20]. For example, Johns Hopkins Children's Center adopted a resuscitation quality bundle-"CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefng and Simulation (CODE ACES2)" [20]. Tey conducted a prospective observational study with this approach and demonstrated improved compliance with AHA CPR guidelines in children with IHCA [20]. Another study simulated cardiac arrests and compared a debriefng-only group versus debriefng and real-time audiovisual feedback. In this study, the debriefng group received a 5-min structured program of post arrest debriefng which included the actual transcript of their own CPR eforts and were counseled on adequate compression depth and rate, time without compressions, chest compression recoil to improve CPR quality to comply with resuscitation guidelines. For audiovisual feedback, CPR-sensing defbrillator was used to record CPR characteristics. Only feedback group received automated feedback messages from the defbrillator reporting CPR quality concurrent with CPR. Tey demonstrated that combination of feedback and debriefng improved CPR performance with more encouraging results compared to either method done alone [21]. Tey found that the combined eforts were shown to have a larger impact on CPR performance improvement [21]. In our study, we combined hands-on training and debriefng and found signifcant improvements in chest compression rates, ventilation rates, and blood pressure monitoring. Although there was no signifcant diference in ROSC before and after QI bundle implementation in our study, the improved compliance with CPR guidelines correlates with the fndings similar to these studies. Hence, we believe our study provides additional evidence towards the impact of implementing the bundled approach in CPR quality and patient outcomes.

Limitations.
Our study has several limitations. First, our study is a single-center study and has a small sample size. However, we believe it would be useful in providing data for developing more QI bundle programs. Second, we did not report survival data in our analysis. Tough the hot debriefng was data-driven, team-focused and conducted several days after the event, it might be associated with the Hawthorne efect, an inescapable phenomenon that can have a dramatic impact on the results. Future studies need to be designed to minimize or nullify the Hawthorne efect.

Future Directions.
In the future, further multicenter studies which could incorporate diferent quality improvement interventions such as resuscitation education and debriefng with appropriate design to minimize or nullify the Hawthorne efect would likely strengthen the evidence related to the resuscitation QI bundle. Tese studies should focus on patient-centric outcomes such as survival to hospital discharge, and short-term and long-term neurologic outcomes among survivors.

Conclusion
Our quality implementation bundle was associated with improvement in compliance with CPR guidelines. Larger, multicenter, prospective, randomized studies are needed to evaluate the outcomes of the resuscitation bundle before it is widely accepted as a standard strategy.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Disclosure
Te fndings of this study were presented as a research snapshot presentation under resuscitation, pediatric II category at 51 st Annual Critical Care Congress of Society of Critical Care Medicine, and the abstract was published in Critical Care Medicine journal [22]. Tis research was performed as part of the employment of the authors (name of the employer/s Children's Hospital of San Antonio and

Conflicts of Interest
Te authors declare that they have no conficts of interest.